"Psychiatric assessment can be intrusive and costly and is not standard in clinical plastic surgery practice ... unless the patient is transsexual," Latham writes.

Compulsory referral of all patients seeking transsexual surgeries may violate the patient's ethical right to self-determination ... to direct what happens to his or her body, and may therefore constitute a form of discrimination."

He says the paper is trying to open up discussion about what it means to have "this kind of kind of ethical discrimination".

Aesthetic plastic surgery is an elective non-life-saving procedure that is undertaken for cosmetic benefit, Latham says.

But previous papers on the ethics of aesthetic plastic surgery unjustly consider transsexuals differently to other people who seek such surgery, he says.

"Many transsexual surgeries differ from cosmetic surgeries only due to the sex of the patient making the request."

For example, he says, it is considered routine for a male patient to have unwanted breasts removed, or a woman to have their breasts reduced or enlarged.

But, if a person who is born female wants breasts removed because they feel male, then it is a considered a "radical" surgery, which requires psychiatric evaluation.

"Psychiatric assessment and a diagnosis of 'gender identity disorder' are required," says Latham.

"When you live in a society that condones aesthetic surgeries, purely electively, then why should these patients who also want something aesthetically changed about their bodies, through plastic surgery, have to have a barrier between them and accessing that surgery."

By contrast, he says, psychiatric assessment for non-transsexual aesthetic surgery occurs only at the surgeon's discretion.

Screening for everyone

Professor David Castle, chair of Psychiatry at St Vincent's Health and the University of Melbourne, finds Latham's paper thought provoking, but he is worried about the idea of removing compulsory screening.

While he sympathises with the discrimination argument, he says gender reassignment is a special case that absolutely requires psychological or psychiatric screening.

"What tends to drive people in terms of gender reassignment is very different from the purely aesthetic outcome. It's more about a functional outcome in terms of their lifestyle in general and also potentially sexuality," says Castle.

"Sometimes you can find people requesting these sorts of procedures who really do have some quite concerning underlying psychiatric issues."

While Latham points to data that suggests transsexuals who undergo plastic surgery are happier with the results than non-transsexuals, Castle says this may well be because of compulsory screening, and he argues the same screening should be applied to everyone undergoing irreversible cosmetic surgery.

"The cosmetic industry should be looking much more closely at all of the people that they see," says Castle.

"If people don't have underlying psychiatric disorders, and if they have a realistic expectation of the outcome of their procedures, they can do very well with cosmetic procedures.

"But there is a subgroup - and they're not insubstantial - that do really badly, and I think it's in everybody's interest that they're screened."

Castle says screening should pick up those who have contraindications for cosmetic surgery, including the 10 to 20 per cent of people going to cosmetic surgeons who have body dysmorphic disorder, those who have very unrealistic expectations about how surgery will change their life, and those who are having surgery to please someone else.

"Everybody should be screened in some way," he says.

Latham says requiring everyone to be screened would be an appropriate alternative to removing the requirement of compulsory screening of transsexuals.

"The main point is that institutions need to go one way or the other," he says.